[Patient involvement in medical care]

Models of doctor-patient relationship may be broadly classified as "paternalistic"(doctor decides, patient complies) and "shared decisions" (doctor informs patient and considers patient's preferences). During recent decades there has been increasing emphasis on respect for the patient's autonomy. Physicians agree that clinical decisions require understanding of how patients view alternative treatment outcomes, and that when they can and wish to do so, patients should participate in the choice of management options. However, involving patients in medical decisions is difficult. Although population surveys have indicated an almost unanimous rejection of the paternalistic model, they have not yielded consistent results on the proportion of patients who want to participate in decision making, and of those who would prefer information and guidance, with a view to following the doctor's advice. A second difficulty relates to method: how should the various options be explained to those who want to participate in decision making? Framing, order of presentation of data and amount of data to be presented have all been shown to affect the way patients perceive aand respond to probabilistic information on treatment outcome. Therefore, there is considerable doubt regarding the applicability of the shared decision model in an unselected patient population. Further research will hopefully identify ways to elicit patient preferences and to communicate information about treatment outcomes, such as life expectancy, morbidity, burdens of taking medication and economic costs. For the present, there seems to be no substitute for the compassionate physician who treats patients with respect and who tries to understand their needs.